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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 345002940
Report Date: 12/19/2024
Date Signed: 12/19/2024 02:01:14 PM

Document Has Been Signed on 12/19/2024 02:01 PM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
SACRAMENTO NORTH ASC, 9835 GOETHE ROAD, SUITE 100
SACRAMENTO, CA 95827
FACILITY NAME:MADISON SQUARE SENIOR LIVING IIFACILITY NUMBER:
345002940
ADMINISTRATOR/
DIRECTOR:		DARIUS O. STIRFACILITY TYPE:
740
ADDRESS:3120 COLORADO ST.TELEPHONE:
(916) 757-0918
CITY:CARMICHAELSTATE: CAZIP CODE:
95608
CAPACITY: 6CENSUS: 5DATE:
12/19/2024
TYPE OF VISIT:Required - 1 YearUNANNOUNCEDTIME VISIT/
INSPECTION BEGAN:
12:15 PM
MET WITH:Darius StirTIME VISIT/
INSPECTION COMPLETED:
02:05 PM
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Licensing Program Analyst (LPA) Cassie Yang arrived unannounced on 12/17/2024 to conduct a required annual inspection utilizing the inspection tool. LPA met with Administrator and explained the purpose of the visit.

During today's inspection, LPA and Caregiver conducted an inspection of the facility. Areas toured included but not limited to: four resident bedrooms, two bathrooms, laundry room, kitchen and the common areas.

LPA observed facility to have two days of perishable and seven days of non perishable food. LPA observed knives, toxins and medications to be locked and secured. LPA observed laundry room to be locked and inaccessible to residents in care. Fire extinguisher observed to be updated with State Fire Marshal seal tag dated October 8, 2024.

It was discussed that Administrator is to audit medications as needed to ensure medications are given as prescribed and for Medication Administration Records are documented correctly .

LPA observed presence of home health and hospice correspondence between agency and facility for R1, R2 and R3. LPA conducted a file review for personnel and resident records. LPA observed the required documents present and completed for residents in care.

At this time, LIC 500 and liability insurance is to be emailed to LPA by Friday December 27, 2024.

No deficiencies cited.

Exit interview and a copy of the report was provided.
SUPERVISORS NAME: Anthony Perez
LICENSING EVALUATOR NAME: Cassie Yang
LICENSING EVALUATOR SIGNATURE: DATE: 12/19/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE: DATE: 12/19/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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